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Sunday, April 22, 2012

So, Andrew Lansley, the UK Health Secretary, is supporting proposals to pay health care workers in poorer areas of the country less. It's as if, after pushing through an NHS Bill that almost no-one in the NHS supported, which allows, some-one stood up and asked "No, I'm still not sure these changes will make care worse for those on low incomes," and so Lansley says, "OK then, how about cutting pay for hose working in the areas that are hardest to staff and hardest to work in. Will that convince you?"

Some background: In 1971 - that's 1971, whern Andrew Lansley was aboout 15 - Julian Tudor Hart published a paper which has become rightly famous. The title has passed into the health lexicon - The Inverse Care Law. It is worth quoting the abstract in full.

"The availability of good medical care tends to vary inversely with the
need for it in the population served. This inverse care law operates
more completely where medical care is most exposed to market forces, and
less so where such exposure is reduced. The market distribution of
medical care is a primitive and historically outdated social form, and
any return to it would further exaggerate the maldistribution of medical
resources."

Let me paraphrase that for the hard of understanding: Places that need health care the most, get the least.

I think there is a good argument that any public health system worth its salt should be thinking about how to tackle the inverse care law. It hasn't been solved yet, either in the UK or in Australia (or, indeed, on a global scale). Andrew Lansley's plan just walks straight in the opposite direction.

I was struck by this quote from the proposal quoted in the Guardian:

The introduction of more sensitive market-facing pay would therefore enable more efficient and effective use of NHS funds." (my emphasis)

I would have thought that effective use of NHS funds would be to improve the health of those with the worst health. And that more efficient use of funds would be to direct funding to these areas preferentially. Clearly, I am wrong. The most effective and efficient use of NHS funds must be to continually reduce pay for those who work in the areas where it is most needed, until no-one works there at all.

There are 2 reasons I care about this, and in a nese, this is my declaration on interest.

I am from the north of England and my work in the UK was in communities who had been devastated by the closure of coal mines and steel works - I was working there about 20 years after this happened, and the recovery was only just happening. So, friends who work in these places still certainly stand to lose out. And, worse, the communities will lose out as they find it harder to attract and retrain staff - especially as the staff will be graduating from universities with bigger and bigger debts, and will need to work in higher paid areas to pay this off.

The second reason is that it also allows me to reflect on the Australian context. The Inverse Care Law is alive and well here - rural and remote areas really struggle to attract doctors (and to be fair, financial reasons are probably not the whole reason for this) as do the poorer outer suburbs of the cities. In my sector of Aboriginal health, pay rates are less than other areas of General Practice, but the need is greatest. There is evidence that seeing a large number of Aboriginal patients reduces billing rates (and so GP income) by 25% - it remains to be seen whether Practice Incentive Payments will make up this gap.

Note also that practices that have a higher number of Aboriginal patients, patients from non-English speaking backgrounds and older patients are those that are more likely to be teaching students and registrars. Anecdotally, most teaching practices feel that they lose income doing this.

I suspect things would not be that different in the UK, though fee for service in Oz certainly has the capacity to exacerbate these discrepancies. The knock on effects on inequalities and on teaching are obvious.

So, Health Secretaries of the World, if you're in the market for differential pay rates, try out this method: make health workers pay inversely proportional to the median income of the area where they work. The higher the population income, the lower the health worker's income.

Naive? Idealistic? Perhaps. But I'd rather be that than actively choosing to worsen inequalities in health.